Screening - Referral - Cyst Aspiration - Mammography - HRT
Family History Referrals --------Breast Cancer Genetic High Risk MRI Screening Study
Management of Women with Breast Problems
(based on Avon Somerset and Wiltshire Cancer Services and BASO guidelines)
Screening should be offered to women between the ages of 50 and 70 according to the guidance issued by the National Breast Cancer Screening Programme. Women over the age of 70 have the right to request breast screening and should call or write to the local breast screening unit (Tower Hill Clinic in Bristol). The management of patients following a screen positive mammography should be the same as for patients presenting with symptomatic disease.
Screening outside this programme is not recommended except for high risk patients identified by either a specialist consultant breast surgeon, oncologist with a special interest in breast disease or medical geneticist. Under these circumstances screening should be under the supervision of the specialist.
Guidance for GPs on symptom investigation
The majority of women who present to the General Practitioner or Practice Nurse with breast symptoms will not have breast cancer.
It is essential that all General Practitioners have established links with appropriate secondary care providers and are able to arrange urgent referral when required. Contracts must include provision for communication to the GP of the diagnosis and proposed treatment.
We would ask you to give us as much information as possible for us to decide the urgency of the referral in your letter. Urgent appointments can be made directly by phone, so that you can give your patient the time and date before she leaves your consulting room, and referral letters faxed directly.
Since the intoduction of the "2 week rule", we have introduced a form for referrals to be faxed to us, appointments will be faxed back within an hour during working hours. Feel free to write a letter as well, general information about the patient is always welcomed.
Recommendation
· Initial investigation of breast symptoms should be by clinical examination. If there is any doubt in the General Practitioner’s mind that the breast is anything other than normal then an opinion from a breast surgeon should be sought.
Symptoms requiring URGENT opinions are:
- Ulceration
- Skin Nodule
- Skin Distortion
- Nipple Eczema
-Recent Nipple retraction or distortion
NON URGENT referral includes:
Guidance on the aspiration of breast lumps by General Practitioners
Recommendations
· Breast lumps should only be aspirated by General Practitioners when they have experience in the technique and when it is very likely that the lump is a cyst ie: when the lumps is smooth and when the patient has had a previous cyst aspirated.
The advantage of the GP aspirating a cyst is the immediate relief of anxiety and avoidance of an out-patient referral. The disadvantage is that if the lesion is solid rather than cystic the imaging appearance may be distorted and interpretation of a subsequent fine needle aspirate may be very difficult. Also a lump may be caused by needling (haematoma) leaving the surgeon uncertain, at subsequent referral, as to whether he/she would have thought that a true lump was present in the first instance. The particular skill and training of the breast surgeon lies in deciding whether a true lump is present or not. It is often difficult to differentiate between a true lump and a lumpy area, even for a surgical specialist in breast disease.
Guidance on the indications for mammography
Recommendation
· Direct access for General Practitioner referral for mammography is not recommended. Open access mammography is unnecessary as access to the clinic is rapid.
Mammography is a screening test and is not appropriate as the sole or initial diagnostic test for symptomatic breast disease. Diagnosis of a breast lesion is based on three complementary aspects - clinical, imaging and cytology, often known as Triple Assessment. A mammogram is not required in all women with breast symptoms. Mammography alone does not exclude a breast cancer and (apart from screening) needs to be performed in conjunction with these other diagnostic modalities. It is seldom appreciated that even palpable breast cancers may not be visible on a mammogram, particularly in younger women.
Even though the radiation dose used in mammography is very low, it is inappropriate under the age of 35 unless there are very special reasons; surgeons should follow the local radiological guidelines.
Women on Hormone Replacement Therapy
Recommendation
Screening for women under the age of 50
Recommendation
Frenchay Family History Breast Screening Clinic - Protocol
Criteria for acceptance onto screening programme
- Based on BASO guidelines
- Aged over 35 or 5 years younger than the youngest affected near relative
- Aged under 50 (Risk is lower over 50 and will enter NHS 3 yearly screening programme)
and:-
Either a, 1 first degree relative with breast cancer diagnosed before age 40.
Or b, 1 second degree paternal relative with breast cancer diagnosed before age 40.
Or c, 2 first or second degree relatives (or one of each) on the same side of the family with breast cancer diagnosed before 60.
Or d, 2 first or second degree relatives (or one of each) on the same side of the family with either breast cancer diagnosed before age 60 or ovarian cancer at any age.
Or e, 1 first degree relative with bilateral breast cancers both diagnosed before age 60.
Or f, 1 first or second degree relative on the same side of the family with both breast and ovarian cancer at any age.
Or g, 3 first or second degree relatives with breast or ovarian cancer at any age.
Or h, 1 first degree Male relative with breast cancer at any age.
(1st degree=Mother, Sister or Daughter, 2nd degree=Grandmother or Aunt)
These criteria broadly cover a greater than 3x relative risk of developing breast cancer.
The screening offered will be initial assessment of the family tree with the use of a computer programme to calculate the risk of carrying a gene and the subsequent risk of developing breast cancer, examination, ultrasound scanning, and mammography. Follow-up will be with 18 monthly mammography.
Do note that even if the woman doesn't reach the above criteria, she may be eligible for the IBIS II Study which has different criteria especially for older women and as well as being randomised to Anastrozole or placebo includes 18 monthly mammography.